This Chartbook on Patient Safety includes a section with results from the National Nursing Home Survey on Patient Safety:

National Healthcare Quality and Disparities Report

This Patient Safety chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (QDR). The QDR includes annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). This chartbook includes a summary of trends across measures of patient safety from the QDR and figures illustrating select measures of patient safety. A PowerPoint version is also available that users can download for presentations.

The Department of Health and Human Services Office of Inspector General issued two new reports that address the identification, reporting and investigation of incidents of potential abuse and neglect of our nation's most vulnerable populations, including seniors and individuals with developmental disabilities. OIG issued an early alert in 2017 based on the preliminary findings of this work. Our resulting work, released in June 2019, identify thousands of Medicare claims that indicate abuse and neglect of beneficiaries, including beneficiaries in skilled nursing facilities. If you suspect someone is the victim of abuse or neglect, contact law enforcement immediately.

Reports:

CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect 

Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated

The Immediate Jeopardy Update Training introduces surveyors and non-surveyors to the revised Appendix Q–Core Guidelines to Determining Immediate Jeopardy. The Core Appendix Q focuses on the key components necessary to establish immediate jeopardy (IJ) under the regulations. 

These key components are:

• Noncompliance.
• Serious harm, injury, impairment, or death that has occurred or is likely to occur. 
• Immediate need for action by the provider/supplier to address the noncompliance.

The Core Appendix Q also contains information about how surveyors should determine whether IJ exists, and it includes a template that surveyors must use to ensure that sufficient evidence exists for each key component of IJ.

All Cause Harm Prevention in Nursing Homes Applying Strategies from the New CMS Change Package

Thursday, January 24, 2019, 3:00pm ET (1 hour) Recording Available.

One-third of SNF residents experience an adverse or temporary harm event, and the majority of those are preventable. As part of CMS’s focus on raising awareness of nursing home safety and to support safer nursing home care across the nation, CMS and the Quality Innovation Network National Coordinating Center released a new resource: a Change Package to prevent all cause harm in nursing homes. The Change Package is a compendium of successful practices of high-performing nursing homes, illustrating how they prevent harm while honoring each resident’s rights and preferences.

Nov. 28, 2017, marks the implementation of some significant changes in how the Centers for Medicare & Medicaid Services (CMS) expects nursing homes to operate—and in the survey process that state surveyors will use to assess those operations. CMS survey-and-certification memo S&C: 17-36-NH gives providers critical information about how to prepare for these changes that are required under Phase 2 of the roll-out of the Reform of Requirements for Long-term Care Facilities (aka Mega-Rule) updating the Medicare/Medicaid conditions of participation. This information includes an advance copy of 696 pages of revisions to the F-tags and the Interpretive Guidance in Appendix PP, “Guidance to Surveyors of Long-term Care Facilities,” of the State Operations Manual. Providers should note that the Appendix PP revisions include new subregulatory guidance for multiple F-tags, not just the Phase 2 regulatory changes.

Here’s a summary of critical news—and what’s still to come: